Indian Institute of Management Shillong

Ph.D. – 2019 (Working Professionals)

_____________________________________________________________________________________
APPLICATION FORM
__________________________________________________________________________________________________________________

A. PERSONAL DETAILS

Name: _____________________________________________________________________________________________
(First Name) (Middle Name) (Last Name)
(Use BLOCK letters only)

Father’s Name: ______________________________________________________________

Click here to
Mother’s Name: _____________________________________________________________ Upload
Passport Size
Date of Birth:__________________ Age in Completed Years (as on 10 June, 2019): ________ Photograph
(DD/MM/YYYY)
Gender: ________________ Blood Group: __________ Marital Status: ___________________
General
Category: _____________ Religion: ____________________ Nationlaity: _________________

No
Are you Differently Abled _______If Yes type of Disability: ________________________% of disability ________

Annual Family Income (Excluding candidate’s income): __________________________

Annual Income of the Candidate (Rs / annum):__________________________________

B. ADDRESS FOR COMMUNICATION:

1. _______________________________________________________________________________________________
2. City : ________________________________ 3. Pin Code _______________4. State____________________________
5. Mobile No: ___________________________ 6. Email Address:______________________________________________
7. Emergency Contact Person: _________________________8. Contact No: _________________________________

C. ADDRESS (PERMANENT RESIDENCE):

1. _______________________________________________________________________________________________
2. City: ________________________________ 3. Pin Code _______________4. State____________________________
5. Mobile No: ___________________________6. Email Address:______________________________________________

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D. ENTRANCE EXAM DETAILS:

Provide score of the test(s) that you have taken:

CAT: ____________ GATE: ____________ GMAT: ___________ GRE: _____________

No
Whether UGC – NET/JRF Qualified (yes / no): _____________ If Yes, Year of Qualification ______________________
Category A
If applying as candidate under exemption from standard tests, Choose Category ______________________

 CATEGORY A: Graduates of PGP programs (2 year fulltime) of IIMs or accredited Institutions (AACSB/AMBA/EQUIS)
with CGPA 6.5 out of 10 or equivalent (minimum 5 years of post PGP experience)
 OR
 CATEGORY B: Government employees of Central/ State Civil Services/PSUs/Banks with more than 12 years of
administrative experience
 OR
 CATEGORY C: Teachers from Institutions of higher education with last qualification from a reputed Institution and
minimum 5 years of teaching experience with proven research acumen.

E. AREA OF YOUR INTEREST FOR RESEARCH:

Organisational Behaviour, Human Resource and Communication
1. Select the Primary area of your interest: ___________________________________________________________
Organisational Behaviour, Human Resource and Communication
2. Select the Secondary area of your interest: _________________________________________________________

F. EDUCATIONAL QUALIFICATIONS:

DEGREE YEAR BOARD/INSTITUTE/ SPECIALISATION DIVISION/

UNIVERSITY GRADES
PG

PG
(Additional)
UG

UG
(Additional)
XII

Others
(if any)

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G. PROFESSIONAL EXPERIENCE (start with most recent):

From To Work Annual No.of Primary Area of

Name of the Job
Designation experience CTC Repo work (Select from
organization Profile
(in months) (In Rs) rtees Drop down box)
Organisational Behaviour, Human R

Organisational Behaviour, Human R

Organisational Behaviour, Human R

Organisational Behaviour, Human R

H. PUBLICATION IN JOURNAL

Journal Year Title of the paper Co-author Vol. Page No. of Citations
No. (Scopus/Web of
Science/ICI)

I. BOOKS AUTHOR/EDITED

Name of the Book Co-Author Publisher Year of Publication

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J. AWARDS/MEDALS/PRIZES/SCHOLARSHIPS/CERTIFICATION/HONOURS

Name of the Institution Conferring the

Sl. Awards/Medals/Prizes/Scholarships/Certification/ Awards/Medals/Prizes/Scholarships/
Year
No. Honours Certification/Honours

1)

2)

3)

4)

K. STATEMENT OF PURPOSE (500 words)

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L. TENTATIVE RESEARCH PROPOSAL (1500 words)

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M. NAME AND ADDRESS OF REFEREES *

Name of the Referee Relationship Affiliation Address E-Mail Contact No.

with the
Referee

* One of the referee should be from your current organization and at a scale above you.

DECLARATION

I hereby declare that the above information given by me is correct and complete to the best of my knowledge and no information
has been distorted. If it is revealed that I have concealed or distorted any information my application may be rejected without
any notice at any point of time.

Place: ____________________ Name: __________________________________

Date: ____________________ *Signature of the Applicant: ___________________

(*Signature is needed only on printed copy. For online submission you can put only your initials. Example: A. K. Sinha, if your
name is Ashok Kumar Sinha)

Important Note: Save a copy of this duly filled-in form (by clicking the save button below or using File->Save As option in
the menu) and send it as an attachment to phd@iimshillong.ac.in.

Note: Ignore any "Submit Button" present by in the Application Form.

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